Early recognition and treatment of Transient Ischaemic Attack (TIA)

Prof. Pierre Amarenco, Paris, France

What is a TIA….

• “Brief episode of neurologic dysfunction caused by focal brain or retinal ischemia, with clinical symptoms typically lasting less than one-hour

• and without evidence of acute infarction”.

Albers GW, Caplan LR, Easton JD et al. N Engl J Med 2002;347:1713-16

TIA : Symptom of stroke or ministroke ?

Four Different Perspectives to define « TIAs »

• In the community: Recognition of transient symptoms to detect patients at risk for imminent

stroke:

– Transient Neurologic Symptoms or

– Acute CerebroVascular Syndrome

• Epidemiology study: differentiiation between transient and permanent symptoms without

necessary brain imaging available (duration might be useful)

• Therapeutic trials: differentiation between TIA without brain lesion from those with brain lesion

(qualifying for brain infarction)

• In the setting of a stroke unit: differentiation between transient symptoms from persisting

symptoms eligible for tPA, and later between transient symptoms with brain lesion (infartion)

and those without (e.g, different prognosis, risk stratification perspective)

Four Different Perspectives to define « TIAs »

• In the community: Recognition of transient symptoms to detect patients at risk for imminent

stroke:

– Transient Neurologic Symptoms or

– Acute CerebroVascular Syndrome

• Epidemiologic study: differentiiation between transient and permanent symptoms without

necessary brain imaging available (duration might be useful)

• Therapeutic trials: differentiation between TIA without brain lesion from those with brain lesion

(qualifying for brain infarction)

• In the setting of a stroke unit: differentiation between transient symptoms from persisting

symptoms eligible for tPA, and later between transient symptoms with brain lesion (infartion)

and those without (e.g, different prognosis, risk stratification perspective)

Four Different Perspectives to define « TIAs »

• In the community: Recognition of transient symptoms to detect patients at risk for imminent

stroke:

– Transient Neurologic Symptoms or

– Acute CerebroVascular Syndrome

• Epidemiology study: differentiiation between transient and permanent symptoms without

necessary brain imaging available (duration might be useful)

• Therapeutic trials: differentiation between TIA without brain lesion from those with brain lesion

(qualifying the neurologic event as a brain infarction)

• In the setting of a stroke unit: differentiation between transient symptoms from persisting

symptoms eligible for tPA, and later between transient symptoms with brain lesion (infartion)

and those without (e.g, different prognosis, risk stratification perspective)

Four Different Perspectives to define « TIAs »

• In the community: Recognition of transient symptoms to detect patients at risk for imminent

stroke:

– Transient Neurologic Symptoms or

– Acute CerebroVascular Syndrome

• Epidemiology study: differentiiation between transient and permanent symptoms without

necessary brain imaging available (duration might be useful)

• Therapeutic trials: differentiation between TIA without brain lesion from those with brain lesion

(qualifying for brain infarction)

• In the setting of a stroke unit: differentiation between transient symptoms from persisting

symptoms eligible for tPA, and later between transient symptoms with brain lesion (infartion)

and those without (e.g, different prognosis, risk stratification perspective)

Current view

• Use the term– “Cerebrovascular syndrome” to qualify any

suspiscion of ischemic stroke (whether transient or permanent, ischemic or hemorrhagic)

• Keep the term– “TIA” for symptoms without brain lesion on

neuro-imaging

Cumulative risk of stroke after TIA

0

5

10

15

20

25

0 30 60 90Days

TIA

Minor stroke

BMJ 2004; 328: 326-8

Cumulative risk of stroke TIA vs minor stroke

Lancet 2005; 366: 29-36

OXVASC

0

2

4

6

8

10

12

14

0 7 14 21 28

Days

Ris

k o

f st

roke

(%

)

OCSP

TIA: diagnosis needed

• 2,416 pts [OXVASC, OCSP, ECST, UK-TIA]• 23% of strokes preceded by a TIA

– 17% same day– 9% day before

– 43% within 7 days before index stroke

Rothwell P et al. Neurology 2005;64:817-820

Very Early Management in a TIA Clinic :

80% stroke risk reduction at 3 months

Rothwell et al. Lancet. 2007

EXPRESSNext day visit

SOS-TIASame day visit (24/24hr)

Lavallée et al. Lancet Neurol. 2007

SOS-TIA

• TIA clinic, 24/24 h, 7/7 d

• Objectives :

To make an urgent diagnosis of TIA

To find out the cause

in less than 4 hours

To prevent a stroke within the next hours/days/weeks

Educational leaflet on TIA

Mailed to:

15 000 PCP, cardiologists, ophthalmologists, emergency physicians, neurologists in Ile-de-France (administrative region of Paris)

Give 300 mg of ASA

Pre-hospital

Yesterday, I was watching TV, and suddendly theRemote control fell down from my right hand. I couldnot move my fingers during 3 minutes. And then, suddendlyI have totally recovered. Is it some fatigue, Doctor?

Do you know?This is a TIAThis patient is at risk for a massive stroke within thenext hours?What to do?Don’t down grade the symptomsTell the patient he is at risk for imminent stroke butthat we can avoid itTell him we have to do immediate diagnostic testingand treatment

TIA symptoms:

Carotid (anterior circulation)• transient monocular blindness• hemiplegie• hemi sensory loss• speech difficulties (aphasia)

Vertebrobasilar (posterior circulation):• hemiplegie (may involved both sides, not at the same moment)• unilateral paresthesia (same)• total or partial visual field defect (one or both sides)• ataxia with gait unstability

SUSPICION of TIA

0 800 888 248N°Vert

24/24 - 7/7Nurse practitioner : Monday - Friday 9h to 17 h

Senior Vascular Neurologist on duty 17h to 9h and w.e.

SOS TIA

TIA POSSIBLE

ADMISSION at the Day Clinic

SOS-TIALavallée et al. Lancet Neurol. 2007

2003-2005

100% of patients had their work-up done in < 4 hrs75% of patients were discharged home 3 or 4 hrs after admission to the SOS-TIA clinic

SOS-TIA Model vs.

Recognition of TIAs - PCPsGPs - Cardiologists - Ophthalmologists

1st Step

Vs.Admission

to TIA Clinic

100%

3rd Step

Discharge

100%75% Admissionto Stroke Unit

25%

LOS

6.5 days

TRIAGEStratifying the risk

According to a quick work-upAnd underlying cause

< 1 dayvs.

2nd StepAdmission

To Stroke Unit

100% ABCD2 score

Usual Care

European Stroke Organisation

2008 Recommendations

Cerebrovasc Dis. 2008;25(5):457-507. Epub 2008 May 6

NICE recommendations

July 2008

ABCD2 Score

Johnston C, Rothwell PM etal. Lancet 2006

Short-Term Risk of Stroke by ABCD2 Score

Johnston C, Rothwell PM etal. Lancet 2006

1622 -> 1176 Definite or possible TIAs

Does ABCD2 score less than 4 allow more time to evaluate patients with TIA ?

Amarenco P, Labreuche J, Lavallée PC, et al. Stroke. 2009

1622 -> 1176 Definite or possible TIAs

SOS-TIA update 2003-2009

HTN/Diabetes/Cholesterol/Smoking…

Genes / Age / Gender / Hs-CRP / ACE / TM …

Predicting Short/Long-Term High-Risk of Stroke/MI

TIA

Stroke/MI

CLINICAL EVENTS

MARKERS OF RISK

MODIFIABLE RISK FACTORS

Stenosis

Plaque

Intima-Media Thickness

DWI/MRI

A-FibOther CSE

Triaging TIAs: MRI

Calvet D et al. Stroke. 2009;40:187-192

ABDC2 + I

0

1

2

3

4

5

6

7

8

9

10

≤1 2 3 4 5 6 7ABCD2 score

OR

fo

r in

farc

tio

n o

n b

rain

im

agin

g

DWI- imaged cohorts

CT- imaged cohorts

Giles M, Rothwell PM, Amarenco P, et al. Stroke 2010

ABDC2 + I

Giles M, Rothwell PM, Amarenco P, et al. Stroke 2010

Causes of Brain InfarctionsCauses of Brain Infarctions

IntracranialIntracranialAtherosclerosisAtherosclerosis

CarotidCarotidPlaque withPlaque with

ArteriogenicArteriogenicEmboliEmboli

Aortic ArchAortic ArchPlaquePlaque

CardiogenicCardiogenicEmboliEmboli

PenetratingPenetratingArteryArteryDiseaseDisease

Flow Flow Reducing Reducing Carotid Carotid StenosisStenosis

Atrial FibrillationAtrial Fibrillation

Valve DiseaseValve Disease

Left Ventricle ThrombiLeft Ventricle Thrombi

SOS-TIAUltra-early Neurosonographic evaluation

in definite TIA13% ECG abnormalities (10% AF)

Carotid US97.3% of 1881pts

Carotid athero

Carotid stenosis ≥70%

DTC97.3% of 1881 pts

Intracranial stenosisOr occlusion

TTE/TEE96%/77% of pts

Aortic arch pl≥4 mmMajor CSEPFO/ASA

65%

8.6%

13.9%

14%2%19%

Lavallée PC, Labreuche J, Meseguer E et al. & Meseguer E, Lavallée PC, Mazighi M, et al. & Slaoui T, Lavallée PC, Labreuche J et al.

SOS-TIA: stratifying the risk with TCD

Meseguer E, Lavallée PC, Mazighi M, et al. Ann Neurol. 2010

SOS-TIAStratifying the risk on the presence of carotid plaque on carotid ultrasound

examination

Risk of combined stroke, myocardial infarction and vascular death from time of presenting withsuspected TIA according to presence or absence of ICA atherosclerosis

Carotid plaque

No carotid plaque

Age and sex adjustedRR=1.83 (95%CI, 0.84-4.01) log-rank, p=0.001

1-yr rate of Stroke, MI, Vasc Death 3.7% vs. 1.3%

N=1756

SOS-TIA: Immediate Preventive Strategy for Mr B.

• Antiplatelet agent, pre-hospital• Blood pressure lowering• Statin therapy (after lipid profile determination in

fasting condition)• Smoking cessation• Anti diabetic treatment• Oral anticoagulant (e.g., Atrial fibrillation)• Carotid endarterectomy (stenosis ≥70%)

CONCLUSIONS• TIA is an emergency: work-up has to be done < 24 hours, in a dedicated organized structure (TIA clinic)

• With fast evaluation = same day discharged for up to 75% of pts (Pt satisfaction/Cost-effectiveness)

• Risk becomes extremely low compared to that expected with a RRR= 80% at 3 months

• TIA clinic should be developed in all comprehensive stroke centres for same day evaluation

• It is no longer possible to wait more than 12 hours to do the evaluation of a TIA

What should be the early management of TIA patients

• Admission to a dedicated structure (no matter the setting)

• Immediate evaluation and treatment• A priori defined immediate process of care

– Brain imaging– Arterial and cardiac evaluation– Blood testing– Full clinical evaluation

• Decision on orientation by a senior stroke specialist: discharged home or admission to SU